Inspection·October 3, 2025

F 0659 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some bag and went with the mouth because that's all I knew how to do. (V10) said she did not know how to attach it either.On [DATE] at 2:55 PM, V10 stated there was tube feeding coming out of R2's tracheostomy during CPR, so they just placed the respiratory bag over his face and turned the oxygen up.The (Local Fire Department) Incident Report dated [DATE] at 5:15 PM documents Fire Department arrived while staff were performing CPR on R2. Staff stated they were bagging the patient's mouth and not his tracheostomy tube due to secretions coming from the tube while CPR was being performed. On [DATE] at 2:37 PM, V22, (Local) Fire Department Chief, stated when his staff arrived to the facility on [DATE], Facility staff were bagging R2 with the BVM (Bag Valve Mask) over the naso-oral pharynx which is not the standard place for the BVM when the resident has a tracheostomy. The BVM should have been via tracheostomy. V22 stated over the past several months, the Fire Department has encountered multiple issues with tracheostomy residents at the Facility, making him question the care they receive, as far as keeping airways clear and patent so the residents can breathe. He stated they get calls for shortness of breath on a tracheostomy resident, and it is often something as simple as suctioning or cleaning of the tracheostomy tube or applicator. He stated these should be part of routine maintenance that he would expect from a facility that allows tracheostomies to be there.On [DATE] at 8:12 AM, V3, Local Fire Department Paramedic, stated R2 was sent to the hospital frequently for tracheostomy secretions and does not think the Facility has the staff they need to care for the residents with tracheostomies.On [DATE] at 9:30 AM, V4, Local Fire Department Paramedic, stated they get called to the Facility every day for suctioning or other non-emergent issues.2-R4's Face Sheet documents R4 was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure with hypoxia and tracheostomy status.R4's MDS dated [DATE] documented R4 was severely cognitively impaired, dependent with mobility and required tracheostomy care, suctioning and oxygen therapy.R4's Care Plan dated [DATE] documents R4 is at risk for complications due to tracheostomy. The interventions include performing tracheostomy care as ordered and as needed and suctioning mouth and tracheostomy as needed.R4's Progress Note dated [DATE] at 4:55 PM documented R4 had several episodes of emesis that day. R4 was found with agonal breathing, emesis and what appeared to be water coming out of his tracheostomy and mouth. EMS was contacted for transport, and there was no documentation that R4's tracheostomy was suctioned at that time.R4 Hospital Record dated [DATE] documents R4 has had multiple troubles with tracheostomy management and partial (mucus) plugs. On arrival to the hospital, R4 had a very dirty, partially plugged tracheostomy, but was breathing much better with no signs of distress after it was cleaned by respiratory therapy.On [DATE] at 11:59 AM, R4 was lying on stretcher in his room with Emergency Medical Services (EMS) present. EMS suctioned out clear, thick, frothy sputum that was bubbling from the tracheostomy. V4, Local Fire Department Paramedic, and V27, Local Fire Department Captain, both stated there was suction tubing in R4's room, but no yankeur (suction tip), so they used their own equipment to suction R4. R4 was transported from the Facility on stretcher at 12:02 PM.R4's Progress Note dated [DATE] at 12:02 PM documents blood was expelled through R4's trachea while being suctioned. There was a scant amount of red clotted blood, and R4 was sent out with EMS.R4's Hospital Record dated [DATE] documents R4 presents due to blood being noted in his tracheostomy at the Facility. Paramedics are highly skeptical as to this history given that when they arrived on scene there was no noted blood and the suction equipment that staff were reporting using was not hooked up to any mechanical suction. Paramedics got normal colored secretions and one small drop of blood from R4's tracheostomy. R4 was seen here 5 days ago after an episode of vomiting and perceived issues with his tracheostomy being obstructed after vomiting. His tracheostomy was suctioned copiously, and the X-ray was unrevealing. R4 has been seen in the ER several times in the last week (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145655 If continuation sheet Page 2 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145655 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bria of Woodriver 393 Edwardsville Road Wood River, IL 62095 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0659 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some and has had normal lab workups.3-R5's Face Sheet documents R5 was admitted to the facility on [DATE] with diagnoses including COPD, chronic respiratory failure, and tracheostomy status.R5's MDS dated [DATE] documented R5 was cognitively intact, independent with bed mobility, required supervision with transfer, and required tracheostomy care, suctioning, and oxygen therapy.R5's Care Plan dated [DATE] documents R5 has potential for difficulty breathing related to bronchiectasis, COPD, chronic respiratory failure, obstructive sleep apnea, and dyspnea.R5's Progress Note dated [DATE] at 10:44 PM documents R5 was transferred to (Local Hospital) to have tracheostomy evaluated. R4 [NAME] EMS that her tracheostomy was supposed to have been replaced last month, but never was. V58, RN, was unable to change it in the Facility. R5's (Local) Fire Department Incident Report dated [DATE] documents, Upon arrival found pt (patient) sitting in a wheelchair at the nurses' station. The nurse advised that the pt was complaining of difficulty breathing and felt like something was in her airway. Pt was able to talk as normal, breathing was normal, and SPO2 (Peripheral Oxygen Saturation) was 94% on RA (Room Air). Visualized the trach opening and nothing noted to be obstructing; however, the area around it appeared to be pus, and the gauze was saturated with saliva and pus. Asked pt when was the last time the trach was last replaced. She advised it was supposed to be replaced over a month ago, and it's not been done yet. Asked the nurse if they have the proper supplies to switch out her trach, and she advised that she didn't know anything about it, she was agency. And just working her {sic} temporarily.R5's [DATE] Hospital Records document R5 was short of breath at Facility. Staff tried to suction her, but had trouble getting to the left (side) and she feels the left side is plugged. R5 was suctioned with removal of mucus plug, then saturations were fine with no further symptoms or distress. R5's [DATE] Hospital After Visit Summary documents R5 was seen for tracheostomy tube change.4-R6's Face Sheet documents R6 was admitted to the facility on [DATE] with diagnosis of acute respiratory failure with hypoxia.R6's MDS dated [DATE] documented R6 was severely cognitively impaired, required partial assistance with rolling from side to side, was dependent with transfer, and required oxygen therapy.R6's Care Plan does not contain any documentation regarding tracheostomy.R6's Fire Department Incident Narrative dated [DATE] documents Fire Department responded for transport to hospital when R6 removed his tracheostomy.R6's Hospital Records dated [DATE] document R6 pulled out tracheostomy in the Facility.R6's Fire Department Incident Narrative dated [DATE] documents Fire Department responded for transport when R6 pulled out his tracheostomy tube. Staff reported R6 was admitted to the Facility two days prior and had pulled out his tracheostomy every day since admission. R6's Hospital Records dated [DATE] document R5 removed his own tracheostomy and was just discharged from (Regional Hospital) earlier today for the same issue.R6's Fire Department Incident Narrative dated [DATE] documents Fire Department responded for transport when R6 removed his tracheostomy and feeding tube. R6's Fire Department Incident Narrative dated [DATE] documents Fire Department responded for transport R6 removed his tracheostomy. This time, staff had replaced R6's tracheostomy, but still wanted him to be transported due to redness around the tracheostomy site.R6's Medical Record does not document any interventions to prevent R6 from removing tracheostomy.On [DATE] at 4:17 PM, V23, Licensed Practical Nurse (LPN), stated she did not receive any training at the Facility regarding tracheostomies.On [DATE] at 4:20 PM, V17, LPN, stated the Facility does not provide routine training on tracheostomy care.On [DATE] at 7:45 AM, V24, LPN, stated she has not had any training in the Facility regarding tracheostomy care. If a resident's tracheostomy ever came out and there was no RN at the Facility she would send the resident to the hospital.On [DATE] at 1:56 PM, V25, LPN, stated she has not had any inservices regarding tracheostomy care in the Facility.On [DATE] at 12:56 PM, V31, CNA, stated she has not had any training in the Facility on CPR for residents with tracheostomies and would (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145655 If continuation sheet Page 3 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145655 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bria of Woodriver 393 Edwardsville Road Wood River, IL 62095 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0659 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete always place the respiratory bag over the resident's mouth.On [DATE] at 1:00 PM, V32, LPN, stated she is not comfortable caring for residents with tracheostomies and did not know how to provide respiratory support to a resident with a tracheostomy needing CPR. She has not had any training regarding tracheostomies in the Facility.On [DATE] at 3:15 PM, V35, Assistant Director of Nursing (ADON), stated there has not been much staff education regarding tracheostomies, and there has been no formal training in the Facility.On [DATE] at 9:03 AM, V2, Director of Nursing (DON), stated she expects nursing staff to be proficient in providing routine tracheostomy care, including suctioning and cannula changes, and know what to do during emergencies.The Facility's Registered Nurse/Licensed Practical Nurse Job Description, Undated, documents, Under the direction of the physician, is responsible for total nursing care to all residents on assigned unit during the assigned shift including responsibility for delegation of duties, resident nursing care, staff performance and adherence by staff members to facility policies and procedures. Remain current in facility policies, procedures and nursing trends by participating in in-service and continuing education programs.The Facility's Facility Assessment reviewed [DATE] documents the Facility provides care for COPD, pneumonia, asthma, chronic lung disease, and respiratory failure. Specialized Rehabilitation Services include Respiratory. Special Care Needs include tracheostomy care and ventilator care.The Immediate Jeopardy and deficiency practice that began on [DATE] was corrected/removed on [DATE] after the Facility took the following actions to correct the noncompliance: Tracheostomy in-service was completed on [DATE], and all nurses, including agency nurses, were educated prior to the start of their next scheduled shift. The abatement was validated with interviews with V15, V25, V48, V50, V56, and V57. Event ID: Facility ID: 145655 If continuation sheet Page 4 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145655 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bria of Woodriver 393 Edwardsville Road Wood River, IL 62095 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to provide Cardiopulmonary Resuscitation (CPR) according to accepted professional standards for 2 of 2 residents (R2, R1) reviewed for CPR in the sample of 6. This failure resulted in R1 and R2 not receiving adequate respiratory ventilation when staff did not provide rescue breathing via R1 and R2's primary airway of tracheostomy. R1 and R2 both died while in the Facility, and death certificates are pending. This Immediate Jeopardy began on [DATE] at 6:40 PM when R1 was found unresponsive, and CPR was not performed in accordance with professional standards. V1 and V2 were notified of the Immediate Jeopardy on [DATE] at 11:37 AM. The surveyor confirmed through observation, interview, and record review that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate implementation and effectiveness of the removal plan.Findings include:1-R1's Face Sheet documents R1 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, asthma, and tracheostomy status. R1's MDS dated [DATE] documented R1 was cognitively intact and independent with mobility.R1's Physician Orders do not document supplemental oxygen orders.R1's Care Plan initiated [DATE] documented R1 was a full code.R1's Progress Note by V34, Registered Nurse (RN), on [DATE] at 10:27 PM documents V11, Certified Nursing Assistant, informed V34 that the R1 appeared blue and to come assess him. Staff initiated CPR and continued until Emergency Medical Services (EMS) arrived. EMS continued resuscitation efforts until (Local Hospital) cleared them to call time of death at 7:14 PM.On [DATE] at 1:15 PM, V34 stated we tried to do CPR for R1 over his tracheostomy, but we did not have the correct tubing to attach it, so we just tried to cover the tracheostomy with a gloved hand and attempted bagging (placing Bag Valve Mask, BVM) over his mouth. On [DATE] at 1:45 PM, V11 stated staff did not provide any ventilation for R1 during CPR and only did chest compressions. There were multiple (BVM) bags in the room, but none would fit over his tracheostomy. The one on the crash cart did not work either, so they continued with compressions, but did not provide any ventilation during the resuscitation.2-R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including anoxic brain damage, paraplegia, respiratory failure, and tracheostomy status.R2's Minimum Data Set (MDS) dated [DATE] documented R2 was severely cognitively impaired, dependent for mobility, and received high concentration oxygen therapy and tracheostomy care.R2's Physician Order dated [DATE] documented R2 was a full code.R2's Care Plan initiated [DATE] documents R2 is a full code and wishes will be honored.R2's Progress Note by V9, Licensed Practical Nurse (LPN), dated [DATE] at 6:00 PM documents, Aides were in room giving patient care when they grabbed nurse and alerted her that resident was unresponsive at 4:50pm, CPR started for 1q0 (10) minutes before EMTS (Emergency Medical Technicians) arrived and took over. EMT performed CPR until 5:30pm when they called timeof {sic} death.On [DATE] at 1:55 PM, V9 stated there were two CNAs whose names she was unable to recall in R2's room caring for him. V9 was standing outside in the hallway with the medication cart waiting for them to finish care so she could go in and give R2 his medications. V9 left for a break at 4:43 PM, and the CNAs let her know at that time R2 would probably need suctioning when they were finished. When V9 returned from break, EMS was in the Facility and had already stopped resuscitation efforts. On [DATE] at 12:43 PM, V8, CNA, stated she was working on another unit when a code was called on the 200 Hall. She ran to R2's room and could tell he was not breathing. V10, Registered Nurse (RN) started compressions, and V8 started bagging R2 by mouth. She was not aware the bag had to be on the tracheostomy and stated, I don't even know how to attach the thing. I have never bagged a trach before. I think that is something we need (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145655 If continuation sheet Page 5 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145655 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bria of Woodriver 393 Edwardsville Road Wood River, IL 62095 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few to be educated on. None of us in there knew. I even asked. (V10) gave me the oxygen and I just took the bag and went with the mouth because that's all I knew how to do. (V10) said she did not know how to attach it either. On [DATE] at 2:55 PM, V10 stated on [DATE] around 4:50 PM, a CNA whose name she cannot remember came and told her R2 was unresponsive. R2's nurse was on break at that time. R2 was a full code, and CPR was initiated. There was tube feeding coming out of R2's trach, so they just placed the respiratory bag over his face and turned the oxygen up. The (Local Fire Department) Incident Report dated [DATE] at 5:15 PM documents, FD (Fire Department) units arrived on scene and found staff bagging the patients mouth and performing CPR on the patient while he was still in bed. Staff states they were bagging the patients mouth and not his trach tube due to secretions coming from the tube while CPR was being performed. FD crew marked the patient was cold to the touch while attempting to find a femoral pulse, no pulse was found. FD crews moved the patient to the floor, continued CPR and ventilation. The BVM (Bag Valve Mask) was taken off the patients mouth, mask was removed, and the BVM was connected to the patients trach tube. Staff left the room and came back a few minutes later with paper work for the patient, showing the patients extensive medical history. The [NAME] and the defib pads were placed on the patient, showing an initial rhythm of asystole. FD crew gained IO access in the left tibial tuberosity. IO drew and flushed. First epi at 1723 (5:23 PM). ACLS protocols were followed with pulse checks every 2 minutes and Epi every 3-5. Initial end tidal reading was an 11. AMA crew arrived on scene and briefed on patient. Patient remained in asystole for the duration of the resuscitation attempt. AMA medic called medical control for directions. Medical control advised crews to terminate resuscitation efforts, per DM 153. FD gathered restock from the ambulance and returned to service.On [DATE] at 2:37 PM, V22, (Local Fire Department) Chief, stated when his staff arrived to the facility on [DATE], Facility staff were bagging R2 with the BVM over the naso-oral pharynx which is not the standard place for the BVM when a resident has a tracheostomy. The BVM should have been via tracheostomy. On [DATE] at 3:15 PM, V35, Assistant Director of Nursing (ADON), stated there is a bag that goes over the tracheostomy when you provide CPR. On [DATE] at 3:20 PM, V2, Director of Nursing (DON), stated there is a bag that goes on the trach, and those BVMs should be at bedside. She was not previously informed of any issues with staff getting the BVMs on the tracheostomy. On [DATE] at 3:33 PM, V1, Administrator, stated standard CPR protocol should be followed for residents with tracheostomies, but the respiratory bag should go over the tracheostomy site or the residents would not be getting air. On [DATE] at 3:50 PM, V33, Medical Director, stated he would expect staff to know how to perform CPR on residents with tracheostomies and would expect the Facility to have the necessary equipment and supplies for both maintenance and emergent situations. The Facility's Tracheostomy Care Policy reviewed 10/2024 documents, It is the policy of this facility that residents with tracheostomies receive care to maintain a patent airway.The Facility's Code Blue Policy reviewed 10/2024 documents, Breathing: provide 2 breaths via ambu or manually if ambu is not available. Continue CPR per BLS guidelines until EMS arrives and takes over CPR.The Facility provided CPR Certificates for Nursing Staff which document V19, V54, and V55, CNAs, did not have CPR certification from the American Red Cross or American Heart Association with hands on, in person training.The Facility's CPR Certification Policy revised [DATE] documents, Staff will have CPR certification from the American Red Cross or the American Heart Association The CPR Certification will be the CPR/BLS for Healthcare Providers level and include in-person training, hands on training.The Immediate Jeopardy and deficiency practice that began on [DATE] was corrected/removed on [DATE] after the Facility took the following actions to correct the noncompliance: Clinical and agency staff were inserviced on performing CPR on residents with tracheostomies, CPR Policy was reviewed, CPR equipment was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145655 If continuation sheet Page 6 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145655 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bria of Woodriver 393 Edwardsville Road Wood River, IL 62095 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0678 Level of Harm - Immediate jeopardy to resident health or safety verified as available in the Facility, CPR audits were initiated, and QAPI Meeting was held. The abatement was validated by review of CPR policy and audits, observation of CPR/tracheostomy equipment and supplies, review of purchase orders for equipment and supplies, and interviews from V2, V6, V10, V13, V24, V25, V34, V39, V42, V44, V45, V47, V49, V51, V52, and V53. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145655 If continuation sheet Page 7 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145655 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bria of Woodriver 393 Edwardsville Road Wood River, IL 62095 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to ensure changes in condition were reported for timely assessment and intervention for 1 of 3 residents (R2) reviewed for change in condition in the sample of 6. This failure resulted in R2 showing a change in condition with dilated pupils, hand to touch cool body temperature and decreased baseline response to care on [DATE] when V11 and V12 were providing care to R2. V11 and V12 stated they did not inform R2's nurse of R2's changes. Approximately 15-20 minutes later, V12 returned to check on R2 and R2 was found unresponsive and Cardiopulmonary Resuscitation (CPR) was initiated. R2 died in the Facility, and death certificate is pending.This Immediate Jeopardy began on [DATE] at approximately 5:00 PM when R2 displayed changes from his baseline that were not reported to his nurse. V1 and V2 were notified of the Immediate Jeopardy on [DATE] at 2:12 PM. The surveyor confirmed by interview, observation, and record review Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the removal plan.Findings include:1-R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including anoxic brain damage, paraplegia, respiratory failure, and tracheostomy status.R2's Minimum Data Set (MDS) dated [DATE] documented R2 was severely cognitively impaired, dependent for mobility, and received high concentration oxygen therapy and tracheostomy care.R2's Physician Order dated [DATE] documented R2 was a full code.On [DATE] at 1:45 PM, V11, Certified Nursing Assistant (CNA), stated she was helping another aide clean R2 on [DATE]. She noticed R2's skin was cool, and he seemed more relaxed than normal. She said usually R2's eyes are wide open and moving from side to side, but this day they were more droopy and he just seemed calmer than normal. V11 did not tell the nurse about these changes and went on to help another resident.On [DATE] at 3:13 PM, V12 (CNA) stated, I've done nursing homes for 30 years. I could tell by (R2)'s eyes that his pupils had dilated a little bit. Around 5:00 PM another young lady helped me clean him up. I said, ‘His pupils are dilated a little.' He was still breathing and everything. We cleaned him up. I couldn't wash his arm because it was really stiff. Usually (R2) tries to bat us away with his little arm that is all curled up, but he was stiff, and we had to lift his arm to wash his armpit. V12 said she did not convey these changes to the nurse and went on to care for another resident. V12 checked back on R2 15-20 minutes later and he was not responding. She told the nurse she thought R2 expired and she needed to go check on him. She said the nurse was moving too slow and it took her one or two minutes to get down to R2's room. When the nurse got there, CPR was initiated.On [DATE] at 1:55 PM, V9, Licensed Practical Nurse (LPN), stated there were two CNAs whose names she cannot remember caring for R2 right before he was found unresponsive. V9 was right outside R2's room with the medication cart waiting them to finish with R2 so she could give him his medications. These CNAs did not tell her R2 had any changes from his baseline, so V9 left for a break. When she returned from break, EMS (Emergency Medical Services) was in the building and had already called R2's death.On [DATE] at 2:55 PM, V10, Registered Nurse (RN), stated a CNA whose name she cannot remember told her R2 was unresponsive. R2's nurse was on break at that time. CPR was performed for 15-20 minutes, then EMS arrived and took over. V10 was checking vital signs and was never able to get anything, like he was already gone.The (Local) Fire Department Incident dated [DATE] at 5:15 PM documents Fire Department arrived on scene while staff was performing CPR on R2. Fire Department Crew attempted to find a femoral pulse and noted R2 was cold to the touch.On [DATE] at 9:30 AM, V4, Local Fire Department Paramedic, stated staff were performing CPR on R2 when they arrived at the Facility. R2 had no femoral pulse and was cold to the touch, so he questioned when R2 was last known to be well.On [DATE] at Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145655 If continuation sheet Page 8 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145655 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bria of Woodriver 393 Edwardsville Road Wood River, IL 62095 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 11:00 AM, V8, CNA, stated R2 was already starting to stiffen up during CPR. On [DATE] at 1:48 PM, V19, CNA, stated R2 was already cold when CPR was being performed. On [DATE] at 2:09 PM, V20, CNA, stated she helped perform CPR on R2 and he was already cold.On [DATE] at 3:50 PM, V33, Medical Director, stated he would expect staff to report any changes in condition to the nurse on duty. On [DATE] at 1:40 PM, V2, Director of Nursing (DON) stated if a resident experiences a change in condition, staff should report it to the nurse. If the resident's nurse is not available, they should report it to another nurse that is available. R2's change of condition was not reported to her, and she had no idea why they would not have reported those changes to the nurse on duty.The Facility's Change In Resident Condition Policy reviewed 10/2024 documents, It is the policy of the facility, except in a medical emergency, to alert the resident, resident's physician and resident's responsible party of a change in condition. The policy does not contain documentation pertaining to communication between nurse aids and licensed nurse staff.The Immediate Jeopardy that began on [DATE] was corrected/removed on [DATE] after the Facility took the following actions to correct the noncompliance: Clinical and agency staff were in-serviced on timely assessments, Notification of Change Policy was reviewed, QAPI meeting was held on [DATE], 24 hour reports were reviewed for change in condition. The abatement was validated through review of 24 hour nursing reports and Notification of Change Policy and interviews with V2, V6, V10, V13, V24, V25, V34, V39, V42, V44, V45, V47, V49, V51, V52, and V53. Event ID: Facility ID: 145655 If continuation sheet Page 9 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145655 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bria of Woodriver 393 Edwardsville Road Wood River, IL 62095 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the Facility failed to ensure nursing staff had the knowledge, skills, and necessary supplies to provide tracheostomy care for 5 of 5 residents (R1, R2, R4, R5, R6) reviewed for respiratory care in the sample of 6. This failure resulted in Cardiopulmonary Resuscitation (CPR) not being performed in accordance with professional standards on R1 and R2 and caused unnecessary emergency hospital transport for R4, R5 and R6. R1 and R2 died in the Facility, and death certificates are pending. This Immediate Jeopardy began on [DATE] at 10:44 PM when staff were unable to replace R5's tracheostomy and adequately suction R5 to ensure airway remains clear and patent. V1 and V2 were notified of the Immediate Jeopardy on [DATE] at 9:03 AM. The surveyor confirmed by record review, interview and observation that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the removal plan.Findings include:1-R1's Face Sheet documents R1 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), asthma, and tracheostomy status. R1's MDS dated [DATE] documented R1 was cognitively intact and independent with mobility.R1's Care Plan initiated [DATE] documented R1 was a full code and was at risk for shortness of breath related to COPD, acute respiratory failure, and tracheostomy,R1's Progress Note by V34, Registered Nurse (RN), documents, (V11, CNA) informed this nurse that the resident appeared blue and to come assess.On [DATE] at 1:15 PM, V34 stated staff tried to provide ventilation for R1 over his tracheostomy, but did not have the correct tubing to attach the respiratory bag, so we just tried to cover the tracheostomy with a gloved hand and attempted bagging over his mouth. On [DATE] at 1:45 PM, V11, Certified Nursing Assistant (CNA), stated staff did not provide ventilation for R1 during CPR and only performed chest compressions. There were multiple respiratory bags in the room, but none would fit over his tracheostomy. The bag on the crash cart did not work either, so they continued with compressions and did not provide any ventilatory support.2-R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including anoxic brain damage, respiratory failure, and tracheostomy status.R2's Minimum Data Set (MDS) dated [DATE] documented R2 was severely cognitively impaired, dependent for mobility, and received high concentration oxygen therapy and tracheostomy care.R2's Physician Order dated [DATE] documented R2 had a tracheostomy.R2's Care Plan documented R2 was a full code and was at risk for complications related to tracheostomy placement.R2's Progress Note dated [DATE] at 8:20 AM documents R2 had two episodes of brown tube feeding colored fluid projecting from trach in a large amount. There was no documentation that R2 was suctioned, and EMS was called for transport to hospital.R2's emergency room (ER) Note dated [DATE] documents R2 came from Facility with tube feeding coming out of tracheostomy. R2 had no distress in the hospital and has been seen frequently for the same thing.R2's Progress Note dated [DATE] at 1:00 PM documents R2 had increased secretions that changed from clear to brownish and in large amount. There was no documentation that R2 was suctioned in the Facility, and R2 was transferred by EMS to the hospital. R2's ER Note dated [DATE] documents R2's trach tube was suctioned, cleaned, and monitored without any additional increased secretions. The cause of R2's symptoms was unclear and R2 would be sent back to the nursing facility.R2's Progress Note by V9, Licensed Practical Nurse (LPN), dated [DATE] at 6:00 PM documents, Aides were in room giving patient care when they grabbed nurse and alerted her that resident was unresponsive at 4:50pm, CPR started for 1q0 (10) minutes before EMTS (Emergency Medical Technicians) arrived and took over. EMT performed CPR until 5:30pm when they called timeof {sic} death.On [DATE] at 12:43 PM, V8, CNA, stated she helped perform CPR on R2 on [DATE]. V10 started compressions, and she placed the respiratory bag Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145655 If continuation sheet Page 10 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145655 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bria of Woodriver 393 Edwardsville Road Wood River, IL 62095 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some over R2's mouth because she was not aware it had to be on the tracheostomy. She stated, I don't even know how to attach the thing. I have never bagged a trach before. I think that is something we need to be educated on. None of us in there knew. I even asked. (V10) gave me the oxygen and I just took the bag and went with the mouth because that's all I knew how to do. (V10) said she did not know how to attach it either.On [DATE] at 2:55 PM, V10, Registered Nurse (RN), stated when CPR was performed on R2 on [DATE], there was tube feeding coming out of R2's tracheostomy, so they just placed the respiratory bag over his face and turned the oxygen up.The (Local) Fire Department Incident dated [DATE] at 5:15 PM documents Fire Department arrived while staff were performing CPR. Staff stated they were bagging the patients mouth and not his tracheostomy tube due to secretions coming from the tube while CPR was being performed. On [DATE] at 2:37 PM, V22, (Local) Fire Department Chief, stated when his staff arrived to the facility on [DATE], Facility staff were performing CPR with the BVM (Bag Valve Mask) over the naso-oral pharynx which is not the standard place for the BVM when the resident has a tracheostomy. The BVM should have been via tracheostomy. V22 stated over the past several months, the Fire Department has encountered multiple issues with tracheostomy residents at the Facility, making him question the care they receive, as far as keeping airways clear and patent so the residents can breathe. He stated they get calls for shortness of breath on a tracheostomy resident, and it is often something as simple as suctioning or cleaning of the tracheostomy tube or applicator. He stated these should be part of routine maintenance that he would expect from a facility that allows tracheostomies to be there.On [DATE] at 8:12 AM, V3, Local Fire Department Paramedic, stated R2 was sent to the hospital frequently for tracheostomy secretions and does not think the Facility has the staff they need to care for the residents with tracheostomies.On [DATE] at 9:30 AM, V4, Local Fire Department Paramedic, stated they get called to the Facility every day for suctioning and other non-emergent issues.3-R4's Face Sheet documents R4 was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure with hypoxia and tracheostomy status.R4's MDS dated [DATE] documented R4 was severely cognitively impaired, dependent with mobility and required tracheostomy care, suctioning and oxygen therapy.R4's Care Plan dated [DATE] documents R4 is at risk for complications due to tracheostomy. The interventions include performing tracheostomy care as ordered and as needed and suctioning mouth and tracheostomy as needed.R4's Progress Note dated [DATE] at 4:55 PM documented R4 had several episodes of emesis that day. R4 was found with agonal breathing, emesis and what appeared to be water coming out of his tracheostomy and mouth. There was no documentation that R4 was suctioned at that time, and R4 was sent to the hospital by EMS.R4 Hospital Record dated [DATE] documents R4 has had multiple troubles with tracheostomy management and partial (mucus) plugs. On arrival, R4 had a very dirty partially plugged tracheostomy, but was breathing much better with no distress after respiratory therapy cleaned it. On [DATE] at 11:59 AM, R4 was lying on stretcher in room with EMS present. EMS suctioned out clear, thick, frothy sputum that was bubbling from the tracheostomy. V4, Local Fire Department Paramedic, and V27, Local Fire Department Captain, stated there was suction tubing in the room, but no yankeur (suction tip), so they used their own equipment to suction R4. R4 was transported out on a stretcher at 12:02 PM.R4's Progress Note dated [DATE] at 12:02 PM documents blood was expelled through R4's trachea while being suctioned. There was a scant amount of red clotted blood, and R4 left with EMS.R4's Hospital Record dated [DATE] documents R4 presents due to blood being noted in his tracheostomy at the Facility. Paramedics are highly skeptical as to this history, given that when they arrived on scene there was no noted blood and the suction equipment that staff were reporting using was not hooked up to any mechanical suction. They got normal colored secretions and one small drop of blood from the tracheostomy. R4 was seen here 5 days (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145655 If continuation sheet Page 11 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145655 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bria of Woodriver 393 Edwardsville Road Wood River, IL 62095 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some ago after an episode of vomiting and perceived issues with his tracheostomy being obstructed after vomiting. His tracheostomy was suctioned copiously, and X-ray was unrevealing. R4 has been seen several times in the ER in the last week and has had normal lab workup.4-R5's Face Sheet documents R5 was admitted to the facility on [DATE] with diagnoses including COPD, chronic respiratory failure, and tracheostomy status.R5's MDS dated [DATE] documented R5 was cognitively intact, independent with bed mobility, required supervision with transfer, and required tracheostomy care, suctioning, and oxygen therapy.R5's Care Plan dated [DATE] documents R5 has potential for difficulty breathing related to bronchiectasis, COPD, chronic respiratory failure, obstructive sleep apnea, and dyspnea.R5's Progress Note dated [DATE] at 10:44 PM documents R5 was transferred to (Local Hospital) to have tracheostomy evaluated. R4 told EMS that her trach was supposed to have been replaced last month, but never was. V58, RN, tried to locate a tracheostomy, but was unable to change it. R5's (Local) Fire Department Incident Report dated [DATE] documents, Upon arrival found pt (patient) sitting in a wheelchair at the nurses' station. The nurse advised that the pt was complaining of difficulty breathing and felt like something was in her airway. Pt was able to talk as normal, breathing was normal, and SPO2 (Peripheral Oxygen Saturation) was 94% on RA (Room Air). Visualized the trach opening and nothing noted to be obstructing; however, the area around it appeared to be pus, and the gauze was saturated with saliva and pus. Asked pt when was the last time the trach was last replaced. She advised it was supposed to be replaced over a month ago, and it's not been done yet. Asked the nurse if they have the proper supplies to switch out her trach, and she advised that she didn't know anything about it, she was agency. And just working her {sic} temporarily.R5's [DATE] Hospital Records document R5 was short of breath at Facility. Staff tried to suction her, but had trouble getting to the left (side) and feels the left side is plugged. R5 was suctioned with removal of mucus plug, then saturations were fine with no further symptoms or distress.R5's [DATE] After Visit Summary documents R5 was seen for tracheostomy tube change.5-R6's Face Sheet documents R6 was admitted to the facility on [DATE] with a diagnosis of acute respiratory failure with hypoxia.R6's MDS dated [DATE] documented R6 was severely cognitively impaired, required partial assistance with rolling from side to side, was dependent with transfer, and required oxygen therapy.R6's Care Plan does not contain documentation regarding tracheostomy.R6's Fire Department Incident Narrative dated [DATE] documents Fire Department responded for transport to hospital after R6 removed his tracheostomy.R6's Hospital Records dated [DATE] document R6 pulled out tracheostomy in the Facility.R6's Fire Department Incident Narrative dated [DATE] documents Fire Department responded for transport to hospital after R6 pulled out his tracheostomy tube. Staff reported R6 was admitted to the Facility two days prior and had pulled out his trach every day since admission. R6's Hospital Records dated [DATE] document R5 removed his own tracheostomy and was just discharged from (Regional Hospital) earlier today for the same issue.R6's Fire Department Incident Narrative dated [DATE] documents Fire Department responded for transport to hospital after R6 removed his tracheostomy and feeding tube.R6's Fire Department Incident Narrative dated [DATE] documents R6 removed his tracheostomy in the Facility. Staff replaced R6's tracheostomy, but want him to be transported due to redness around the tracheostomy site.R6's Medical Record does not document any interventions to prevent R6 from removing tracheostomy.On [DATE] at 4:17 PM, V23, Licensed Practical Nurse (LPN), stated she did not receive any training at the Facility regarding tracheostomies.On [DATE] at 4:20 PM, V17, LPN, stated the Facility does not provide routine training on tracheostomy care.On [DATE] at 7:45 AM, V24, LPN, stated she has not had any training in the Facility regarding tracheostomy care. If a resident's tracheostomy ever came out and there was no RN at the Facility, she would send the resident to the hospital.On [DATE] at 1:56 PM, V25, LPN, stated she has not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145655 If continuation sheet Page 12 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145655 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bria of Woodriver 393 Edwardsville Road Wood River, IL 62095 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete had any education regarding tracheostomy care in the Facility.On [DATE] at 12:56 PM, V31, CNA, stated she has not had any training in the Facility on CPR for residents with tracheostomies and would always place the respiratory bag over a resident's mouth.On [DATE] at 1:00 PM, V32, LPN, stated she is not comfortable caring for residents with tracheostomies and does not know how to provide respiratory support to a resident with a tracheostomy needing CPR. She has not had any tracheostomy training in the Facility.On [DATE] at 2:00 PM, V16, CNA, stated she wishes CNAs were allowed to suction residents because sometimes nurses are so busy and she thinks it would cut back on sending residents out to the hospital and save a lot of people. On [DATE] at 3:15 PM, V35, Assistant Director of Nursing (ADON), stated there has not been much staff education regarding tracheostomies, and there has been no formal training in the Facility.On [DATE] at 9:03 AM, V2, Director of Nursing (DON), stated she expects nursing staff to be proficient in providing routine tracheostomy care, including suctioning and cannula changes, and know what to do during an emergency.The Facility's Tracheostomy Care Policy revised 10/2024 documents, It is the policy of this facility that residents with tracheostomies receive routine care to maintain a patent airway. Suction as needed. Cleanse stoma site. Document appropriately.The Facility's Facility Assessment reviewed [DATE] documents the Facility provides care for COPD, pneumonia, asthma, chronic lung disease, and respiratory failure. Specialized Rehabilitation Services include Respiratory. Special Care Needs include tracheostomy care and ventilator care.The Immediate Jeopardy and deficiency practice that began on [DATE] was corrected/removed on [DATE] after the Facility took the following actions to correct the noncompliance: Tracheostomy in-service was completed on [DATE], and all nurses, including agency nurses, were educated prior to the start of their next scheduled shift. The abatement was validated with interviews with V15, V25, V48, V50, V56, and V57. Event ID: Facility ID: 145655 If continuation sheet Page 13 of 13